Enacted in 2014, New York’s Surprise Billing Law was designed to protect consumers from out-of-network emergency and surprise bills and establish an Independent Dispute Resolution (IDR) process to resolve payment disputes between health plans and providers. While the law has shielded millions of patients from unexpected medical costs, high-price providers are flooding the IDR process to generate excessive payments.
Who’s Abusing the IDR Process?
t’s not primary care physicians but rather high cost specialists such as anesthesiologists, neurosurgeons, orthopedists and plastic surgeons making health care more expensive for consumers, employers and the State Medicaid program.
Update Deployment
Vivamus magna justo, lacinia eget consectetur sed, convallis at tellus. Donec sollicitudin molestie malesuada.
Fully Configurable
Donec rutrum congue leo eget malesuada. Vivamus magna justo, lacinia eget consectetur sed, convallis at tellus.
White Label
Praesent sapien massa, convallis a pellentesque nec, egestas non nisi. Cras ultricies ligula sed magna.
DR Abuse in Medicaid.
The IDR process was intended for commercial insurance and does not differentiate between commercial insurance and Medicaid coverage when determining the reasonableness of the non-participating provider’s fee. High-priced specialists are exploiting this loophole to charge higher rates than what Medicaid would reimburse. The number of Medicaid claims submitted for IDR has grown from 778 in 2021 to over 14,000 in 2024, a 1,700% increase, costing hundreds of millions of dollars above what Medicaid would have reimbursed for the same services without the IDR process. These dollars should be used to provide care to the most vulnerable residents, not putting more money in the pockets of well compensated specialists.
IDR Abuse in
Commercial Coverage
When resolving payment disputes, the IDR process uses the 80th percentile of billed charges – essentially what 80% of physicians in a particular region charge – as the benchmark, which tends to be significantly higher than the negotiated rates that insurers pay for in-network care. A 2022 analysis of New York’s IDR process found payments for nonemergency out-of-network services increased by 24%. The escalating payment amounts reward providers for overusing the process. Since 2020, there has been a nearly 10-fold increase in the use of IDR, as the number of cases in New York has grown from 1,126 to over 10,200 in 2024. These inflated payments lead to higher health care costs for consumers and employers.
What’s the Solution?
Governor Hochul’s FY2027 Executive Budget includes several sensible reforms – Part T of PPGG – to address providers’ abusive price practices. This includes exempting Medicaid from the IDR process, changing the benchmark, and establishing a cap on payments. These measures will stop providers from abusing the IDR process to charge excessive prices, making health care more affordable for consumers, employers and taxpayers, and ensuring vulnerable New Yorkers have access to critical services.
Nam lacinia arcu tortor, nec luctus nibh dignissim eu nulla sit amet maximus.
-
Nam lacinia arcu tortor, nec luctus nibh dignissim eu nulla sit amet maximus.
-
Vivamus magna justo, lacinia eget consectetur sed, convallis at tellus.
